GME Research Review

GME Research Review is a monthly newsletter where internationally recognized experts select, summarize, and provide a clinical commentary on the latest published research in psychiatry. Each summary has been derived from the relevant article’s abstract and the clinical commentary has been provided by our expert.

Objectives: The purpose of this study was to explore the polarity of affective and relational experience (ie, feeling all good or all bad; Beck, Freeman, & Davis, 2004; Kernberg, 1975; Linehan, 1993) over the course of a 21-day experience-sampling diary in adults with borderline personality disorder (BPD) and a comparison group of healthy adults. Additionally, this study investigated the association between the polarity of affective and relational experience and impulsive/maladaptive behaviors commonly exhibited among individuals with BPD.

Participants were trained to use a personal digital assistant (PDA) in order to complete the experience-sampling diary. The PDA used a 5x/day random signaling schedule to assess state affect (eg, disappointed, tense, afraid, sad, angry, satisfied, energetic, happy, enthusiastic, calm), relational experiences (eg, how content they were with an important person in their lives, how cared for they felt by this person, how irritated and angry they were with this person, etc), and behaviors (eg, excessive spending, binge eating, risky sexual behavior, substance use, and self-injury).

The mean number of completed entries for the entire sample was 74, SD=20.66 (71% compliance), with no significant group differences in the number of entries completed. Researchers applied multilevel modeling techniques (Rafaeli, Rogers, & Ravelle, 2007) to capture the within-person covariance of momentary reports of negative and positive features of experience, either affective or relational.

Conclusions: Compared to psychiatrically healthy adults, individuals with BPD are more likely to demonstrate polarity of both affective and relational experiences when these phenomena are repeatedly measured over time. Polarity in reported affective and relational experience is associated with increased frequency of risky and impulsive behaviors. The results support contemporary models of interpersonal functioning in BPD suggesting that treatment should decrease extremes in affect and in ways of thinking about others.

Clinical CommentaryBy using experience sampling over a 3-week time frame, this study provides empirical data to support clinical observations that individuals with BPD are often extreme in their ways of thinking about others, and in experiencing affect. Importantly, this study also points to the critical link between polarity in affect and relational experience and common impulsive behavior among individuals with BPD. The use of structured interviews, a prospective design and multi-level modeling, are methodological strengths. A next step in this area of research might be to move beyond comparison of individuals with BPD to healthy controls, by adding other clinical comparison groups. Such research would better characterize the relationships among interpersonal stress, affect, and relational functioning in BPD, specifically, compared to other clinical groups. In addition, the present study provides a terrific framework for future researchers to more precisely examine the mechanisms which predict the dynamic unfolding of affective and relational polarity. Understanding the predictors and temporal course of these phenomena will be an important next step in developing novel interventions designed to improve interpersonal functioning in BPD.

Objectives:This study used behavioral and functional neuroimaging methods to examine interpersonal sensitivity (ie, accuracy identifying others’ affective states) among individuals with borderline personality disorder (BPD) and healthy controls. Individuals with BPD have been shown to have impairments in the ability to mentalize (ie, accurately identify others’ mental states), yet in some studies have exhibited enhanced abilities in identifying affective states in others. This study was designed to help clarify whether interpersonal hypersensitivity is characteristic of BPD and to elucidate the underlying neural structures associated with this interpersonal process.

Participants were presented with 36 black-and-white original pictures of eye gazes (12 negative, 8 positive, and 16 neutral stimuli) from the RMET paradigm. Thereafter, participants were required to choose one out of four words (three distracter words and one correct word) that describe the mental state of the person in the photograph seen before as quickly and accurately as possible.

Participants were given a short practice, then the experimental procedure started. Each 25-s trial consisted of a 4–6 s jittered fixation cross, a 5-s presentation of a RMET picture (negative, positive, or neutral), a 10-s rating period and again a 4–6-s jittered fixation cross.

Conclusions: BPD patients demonstrated superior mental state discrimination in a standardized behavioral measure than healthy controls. The results of the present study support the hypothesis of Krohn, which suggests that individuals with BPD have enhanced mentalizing abilities in spite of problems in social relationships. Activation in the amygdala, left temporal pole, and left inferior frontal gyrus in combination provides indirect support to the notion that BPD patients may “resonate” with others’ mental state in their own emotional response. This would provide an intuitive emotional evaluation of others without reflexive awareness and top-down elaborative processing.

Clinical CommentaryThis study helps explain the conflicting results in the literature concerning BPD and the discrimination of others’ mental states, or mentalization. Consistent with some previous research, the study findings lend further credence to the clinical observation that patients with BPD may be especially sensitive to others’ affective states. The authors reported that individuals with BPD have a more innate, automatic connection to the emotional states of others than healthy controls. The paper focused on three brain regions as evidence of this apparent ability to “resonate” with the mental states of others. This is an interesting study that has taken an important incremental step in this area of research. Understanding patterns of neural activation during clinically relevant interpersonal processes such as mentalization is critical to the development of next-generation interventions for BPD. One next step that could emerge from this research might be to examine neural and behavioral processes that dynamically unfold downstream following the identification of others’ affective states. Such research would help to characterize vulnerabilities in interpersonal processes that emerge after initial mental state discrimination of others. Additionally, clinically relevant contextual factors (eg, social rejection) need to be incorporated into the design of future studies on this topic in order to enhance the ecological validity of such research.

Objectives: According to Linehan's biosocial model, the core characteristic of borderline personality disorder (BPD) is emotional dysregulation. Most studies have found that patients with BPD report greater self-reported intensity of negative emotions compared to healthy controls. However, emotional hyperreactivity in BPD patients has not been consistently observed in experimental studies. Further, reactivity to discrete emotional stimuli has not been sufficiently assessed among individuals with BPD. Although several studies have examined emotional processes in BPD, most have attempted to induce broad affective states (positive or negative; Rosenthal et al., 2008). Moreover, few studies have assessed emotional responses to positive emotions. In these two experiments, researchers investigated two components of Linehan's model of emotional dysregulation in BPD: baseline emotional intensity and emotional reactivity.

Methods:

Participants: A total of 60 women, 30 with BPD diagnosis and 30 age- and sex-matched healthy subjects (HCs). All participants were Spanish-speaking Caucasians.

Inclusion criteria for the BPD subjects: (a) female ages 18 to 45; and (b) a diagnosis of BPD according to DSM-IV criteria as assessed by two semi-structured diagnostic interviews (SCID-II; Gómez-Beneyto et al,1994, and DIB-R; Barrachina et al, 2004). Exclusion criteria for the BPD subjects: (a) acute psychotic episode, or current affective or eating disorders according to DSM-IV criteria; (b) current substance misuse or dependence; and (c) severe physical conditions, eg, heart or respiratory illness, neurological disease, or brain injury.

Procedures: In the first experiment, BPD patients were compared to healthy controls (HC) to evaluate emotional responses to six emotion-eliciting film clips, each of which was created to elicit one of the following six discrete emotions: anger, fear, disgust, sadness, amusement, and a neutral state. Skin conductance level, heart rate, and subjective emotional response were recorded during each film clip.

First, participants completed the Positive and Negative Affect Schedule (PANAS) to assess baseline self-reports of emotional intensity. Then, the following steps were repeated for each film clip and each subject: (a) baseline physiological measures were recorded for 1 min; (b) the emotion-eliciting film was presented; and (c) subjects self-reported present affective states.

In the second experiment, the same groups were compared to evaluate emotional reactions to films containing content on sexual abuse, emotional dependence, and abandonment /separation, all of which are associated with clinical features of BPD.

Procedures for the second experiment were the same as in the first, except that only three films (with BPD-related content) were shown.

Measures: The MSI-BPD (Zanarini et al, 2003), which consists of 10 true/false questions, was used as a screening instrument for BPD in HCs; PANAS (Sandín et al, 1999), which measures affect state through 20 items, 10 for Positive Affect (PA) and 10 for Negative Affect (NA); Self-Assessment Manikin (SAM; Bradley and Lang, 1994), which evaluates three major affective dimensions: pleasure, arousal, and dominance; and Discrete Emotions Questionnaire (DEQ; Rottenberg et al., 2007), which consists of 18 items that target various emotional states. Physiological data were recorded using the Biofeedback X-pert 2000.

Emotional stimuli: A set of emotion-eliciting film clips that had been previously validated in a Spanish sample (PIE; Fernández, et al, 2011).

For DEQ scores, a 6×5×2 (respectively: six emotions by five DEQ emotional labels by two groups) repeated measures ANOVA was performed. A significant main effect [F(24,751)=1.8, P=.015] was found and a significant group effect for amusement [F(1,55)=5.8, P=.019] and disgust films [F(1,55)=4.5, P=.039]. Post hoc analyses for the amusement film showed no significant differences between groups for DEQ amusement label score but BPD subjects presented significant higher scores on the DEQ anger label [F(1,58)=9.5, P=.003] and the DEQ disgust label [F(1,58)=6.1, P=.017].

Experiment 2: Baseline scores: As in Experiment 1, PANAS scores were significantly different between groups, but baseline physiological activation was not significantly different between groups.

For DEQ scores a 3×5×2 (respectively: three BPD-related stimuli by five DEQ labels by two groups) repeated measures ANOVA was performed. Results showed a main effect [F(12,602)=2.1, P=.016] and a group effect for sexual abuse [F(1,51)=21.3, P<.001] and emotional dependence films [F(1,51)=13.2, P=.001].

For DEQ scores, an effect of history of sexual abuse was only observed for the fear label [BPD with sexual abuse M=4.2, SD=2.5; BPD without sexual abuse M=1.7, SD=1.2; HCs M=2.2, SD=1.2; F(2,53)=4.2, P=.02], where BPD subjects with a history of sexual abuse presented significantly higher scores compared to BPD patients without a history of sexual abuse and HCs.

Conclusions: Although self-reported negative emotions at baseline were stronger in the BPD group, physiological measures showed no differences between the groups. BPD subjects demonstrated no subjective heightened reactivity to most of the discrete emotion-eliciting films. However, subjective responses to amusement and “BPD-specific content” films revealed significant between-group differences. These findings are consistent with previous research and suggest that emotional intensity appears to be a core characteristic of BPD. In contrast, generalized heightened emotional reactivity across stimuli did not characterize the BPD sample in this study.

Clinical CommentaryThis study examined two aspects of Linehan’s (1993) biosocial model of BPD: (1) baseline emotional intensity and (2) emotional reactivity. The results are very clinically relevant. Although BPD patients have traditionally been conceptualized as “more reactive,” this study suggests stronger emotional intensity prior to affective cues may better characterize the emotional dysfunction in BPD than generally heightened emotional reactivity. It is important to note that this study and others before it have found some evidence pointing to the role of contextual factors in the elicitation of emotional reactivity in BPD. For example, BPD-specific emotional triggers related to traumatic personal history may be likely to differentially elicit negative affect in BPD. Next-generation interventions for BPD targeting emotional dysfunction need to be developed to directly reduce general emotional intensity. However, it is premature and inappropriate to abandon the idea that emotional reactivity is not relevant in BPD. Instead, the specific contextual factors among individuals with BPD that differentially predict the onset of emotional reactivity need to be better characterized.

Objective: Difficulties in emotion regulation are a core feature of borderline personality disorder (BPD). Individuals with BPD also report higher levels of experiential avoidance (EA) compared to controls. These constructs have never been studied concomitantly in adolescents. First, given the conceptual similarity of difficulties in emotion regulation and EA, the authors sought to determine whether EA provides incremental validity, above emotion dysregulation, in its association with borderline features. Second, EA was explored as a mediator in the relationship between difficulties in emotion regulation and borderline features.

Borderline features were measured using the 24-item self-report Borderline Personality Features Scale for Children (BPFSC).

Experiential Avoidance was measured using the 17-item self-report Avoidance and Fusion Questionnaire for Youth (AFQ-Y).

Difficulties with Emotion Regulation were measured using the Difficulties with Emotion Regulation Scale (DERS).

Internalizing and Externalizing Symptoms were measured using the 112-item Youth Self-Report (YSR) questionnaire.

Pearson correlations were used to establish a relationship between variables of interest, and hierarchical linear regression was used to determine whether EA predicts borderline features over and above emotion dysregulation.

Experiential avoidance made an independent incremental contribution in its association with borderline features, above and beyond difficulties with emotion regulation, gender, and internalizing and externalizing symptoms.

Conclusions: These results support a relationship between EA and BPD features in adolescents, consistent with findings of a relationship between BPD and EA in adults. Further, EA accounted for BPD features in inpatient adolescents over and above emotion dysregulation. Future studies should be conducted to determine whether these results can be replicated in other adolescent samples (eg, in a sample that is not solely inpatients) and using other methods to measure constructs of interest (eg, behavioral, interview).

Clinical Commentary These results support the growing evidence pointing to experiential avoidance as an important therapeutic target for individuals with BPD features. This is the first study to empirically demonstrate the significance of experiential avoidance to BPD features in an adolescent sample. These results also indicate that experiential avoidance may be distinct, to some degree, from more general difficulties with emotion regulation and may be important to target in therapies for adolescents with BPD features. A next step in this area of research might be to more carefully examine the relationships among EA, emotion regulation difficulties, and BPD symptoms over time using prospective methods from adolescence into adulthood.

Objectives: The aim of this study was to determine if patients with borderline personality disorder (BPD) present with higher emotional response than healthy controls in a laboratory setting. Fifty participants (35 patients with BPD and 15 healthy controls) underwent a negative emotion induction procedure (presentation of standardized unpleasant images). Subjective emotional responses and biological reactivity (ie, salivary cortisol and alpha-amylase) were measured at several points during the procedure.

Methods:

Recruited subjects included 28 outpatients with BPD (on medications at the time of the experiment; exclusion criteria for this group included a range of comorbid Axis-I disorders or a current severe medical condition, current psychotherapy, participation in a similar study or knowledge of the study) and 13 healthy control subjects (employees at the hospital, with no Axis-I, Axis-II, or substance abuse)

Self-report measures were used to assess depression (measured using the Hamilton Rating Scale for Depression), psychopathology (measured using the Brief Psychiatric Rating Scale), emotional arousal (measured using the Self-Assessment-Manikin), mood state (measured using the Profile of Mood States and the Positive and Negative Affect Schedule), and perceived stress level (measured using the Perceived Stress Scale).

Salivary cortisol (sCORT) was used as a measure of subjects’ free fraction (ie, the bioavailable fraction) of blood cortisol and salivary alpha-amylase (sAA) was used as an indirect indicator of SNS activity.

Laboratory sessions took place in a set time of day in a set room with consistent temperature and lighting. Subjects were told to wake up before 8 am, and to not take any substances or perform strenuous exercise prior to the study.

The emotion-induction stimuli used 24 high activation, negative valence pictures taken from the International Affective Picture System (IAPS).

Self-report questionnaires and cortisol samples were taken at four time points: Baseline, Emotional Induction following the first 12 pictures, Emotional Induction following the last 12 pictures, and after completion of the study.

Results:

Outcomes

Self-Report

Salivary Cortisol (sCORT)

Salivary alpha-amylase (sAA)

Baseline

All PANAS and POMS subscales showed significantly higher scores in the BPD group vs HC

The BPD group reported significantly lower SAM-Valence and SAM-Dominance ratings than the control group

Levels of sCORT are lower in BPD group than control group

No significant between-group differences

Emotion Induction

The BPD group reported significantly lower SAM-Dominance ratings than the control group

No significant between-group differences

Levels of sAA significantly higher in BPD group than control group

Emotion Induction 2

The BPD group reported significantly lower SAM-Dominance ratings than the control group

No significant between-group differences

Levels of sAA significantly higher in BPD group than control group

Post-study

The BPD group reported significantly lower SAM-Dominance ratings than the control group

No significant between-group differences

No significant between-group differences

Conclusions: Consistent with prior research, individuals with BPD reported higher negative emotional intensity at baseline; however, contrary to expectations driven by Linehan’s biosocial model, these findings indicate that individuals in the BPD group did not demonstrate higher emotional reactivity to negative stimuli, nor did they show a distinct pattern of recovery when compared to healthy controls. Specifically, there were no significant between-group differences in self-report or physiological negative affective reactivity. However, this may be due to the low baseline levels of cortisol in the BPD sample. Additionally, elevated sAA in the BPD group does reflect some degree of sympathetic activation; however, further studies using more BPD-specific emotion inductions, different types of emotional induction, and different measures of reactivity are needed to clarify the trends observed in this study. Of note, the emotion-induction measure used was insufficient to induce negative affect in either sample, which complicates the interpretation of these findings.

Clinical Commentary These findings do not support the idea that individuals with BPD are more generally emotionally reactive to standardized emotional cues. Although future research is required to specify the types of stressors effective at inducing negative emotion in BPD samples, this might point to a contextual specificity in the nature of stressors that will be emotionally arousing to this population. What does seem to set individuals with BPD apart from healthy controls in this study, and in other recent studies, is self-reported negative affective intensity at baseline. It may be useful in future studies to examine the variability of emotional intensity in BPD, and to begin exploring ways to reduce negative emotional intensity in controlled laboratory settings. Identification and optimization of laboratory-based methods to reduce negative emotional intensity in BPD could provide the groundwork needed to help develop new approaches for behavioral interventions.

Objectives: Using Linehan's biosocial model, the authors of this review conceptualize emotion dysregulation in borderline personality disorder (BPD) as consisting of four components: emotional sensitivity, heightened and labile negative affect, a deficit of appropriate regulation strategies, and a surplus of maladaptive regulation strategies. Research is reviewed to support and characterize each of these components of emotional dysfunction in BPD.

Conclusions: Individuals with BPD show deficits in multiple domains of emotion regulation. Specifically, evidence suggests that individuals with BPD: (1) demonstrate a negative bias when identifying facial expressions of emotion; (2) experience heightened negative affect, particularly affective instability and reactivity; (3) demonstrate low distress tolerance; and (4) are prone to maladaptive emotion regulation strategies such as rumination, thought suppression, experiential avoidance, and impulsive behaviors. Although these findings help highlight the importance of emotion dysregulation in BPD, the continued presence of mixed findings and conflicting evidence points to an underlying issue in definitional clarity in research on emotion regulation in BPD. In order to clarify the particular emotion-regulation deficits relevant to BPD, we require more research that utilize precise, specific terminology to define affective processes and clear methodologies that can help to clarify the contexts in which individuals with BPD do and do not experience difficulty with emotion regulation.

Clinical CommentaryThese findings support the widespread notion that emotion dysregulation is essential to target in any treatment designed for individuals with BPD. One construct that this study highlights as particularly important to address in treatment is distress tolerance. Distress tolerance might provide some protection against BPD symptoms and self-injurious behavior, particularly in those who experience intense negative affect. Another skill that it is particularly important to focus on in therapeutic interventions is building emotion-regulation strategies that the patient feels are effective in managing negative affect. By promoting adaptive emotion-regulation strategies, we can hopefully reduce reliance on maladaptive emotion-regulation techniques such as self-harm. A key point made by the authors is that research in this area must specify clear processes underlying emotional dysregulation. The term emotion dysregulation may be rendered somewhat meaningless if it continues to be used broadly when referring to problems in BPD or in psychopathology more generally. Instead, researchers must discontinue the use of this vague term and replace it with clearly operationalized processes capable of being directly observed.

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